Pressure Ulcers Can Wreck Your Life! Preventing and Managing Skin Problems After Spinal Cord Injury

Pressure Ulcers Can Wreck Your Life! Preventing and Managing Skin Problems After Spinal Cord Injury

>>Deborah Crane: So I’m
going to be starting off to talk a little bit
about pressure ulcers, and hopefully they
won’t wreck your life, but that was our catchier title that Pressure Ulcers:
What You Should Know. So we’ll just get started. These are learning objectives, if you are getting any
continuing education credit. So the first one
is that at the end of this presentation you’ll
be able to name causes of pressure ulcers in the
spinal cord injury population; list strategies for
preventing pressure ulcers in the SCI population,
explain what to do when a new pressure
ulcer appears; and then also name basic
treatment strategies for more severe pressure ulcers. So just to quickly
review the definition, I think it’s pretty obvious. It’s an ulcer or a sore that
is often caused by pressure, but there’s actually a National
Pressure Ulcer Advisory Panel that made a formal definition, they said that “a pressure
ulcer is a localized area of tissue necrosis
that tends to develop when soft tissue is compressed
between a bony prominence and an external surface for
a prolonged period of time.” So basically tissue death when
the soft tissue gets squeezed between a firm spot and
something external to your body. So I’ll talk a little bit about
the epidemiology or prevalence of pressure ulcers, and
then I will go on to kind of some causes and
prevention strategies. So to start, about 20 to 66% of
people with spinal cord injuries that are hospitalized — sometime after their
spinal cord injury, so that’s not the
initial hospitalization when you first get
injured, but sometime later, either for medical or surgical
treatment, rehabilitation, or long-term care
develop pressure ulcers. And I think this is an
important point, because I think if you’re injured in the Seattle
area, you end up at Harborview or the University Hospital
or the VA Hospital, you’re often dealing
with physicians — or you should be dealing with
physicians that know a lot about spinal cord injury. But if you happen to live more
remotely or you’re traveling and you get sick and you
end up in a hospital, a small hospital far away
from people that know much about spinal cord injury, you
or your family might know more about spinal cord injury
than any of the other people, the nurses or the physicians
that you’re working with. So I think in those settings
it’s really important to advocate for yourself and to be telling the
different providers that you are at risk for skin breakdown. Hopefully people know that, but you really may find
yourself being the expert on spinal cord injury if you’re
somewhere other than the center like we have here, where
people know quite a bit about spinal cord injury. And then we also know that
about one-third of people with new spinal cord injury
develop pressure ulcers, so that’s about 30% or so that
come through in patient rehab with new injuries
end up getting sores. So why do we care? Unless we’re going to be
cosmetic, really concerned with our cosmetic appearance
or models, it may not seem that important, but there’s
actually some pretty important reasons why we should
care about pressure sores. So first it’s a common
cause of rehospitalization. Most folks that I’ve encountered
that were hospitalized for awhile after they first
had spinal cord injury, never want to be in
a hospital again. So I think that’s a pretty big
motivator in and of itself. Almost 40%, 39%, of people
rehospitalized in the first year after their spinal cord
injury are admitted for pressure ulcers, so
it’s pretty common to end up in the hospital
again because of a sore. And then about one-third,
or 34% of people with a spinal cord
injury end up requiring 3 or more hospitalizations
throughout the rest of their lifetime for
treatment of pressure sores. So if you want to stay
out of the hospital, you pretty much want to
prevent a pressure sore. We also know that when people
have pressure sore they often have increased care needs. So you may be fairly independent or perhaps completely
independent with your care, and then develop a pressure sore
and all of a sudden need a lot of help, or need
some help and all of a sudden need a
whole lot more help if you have a significant
pressure sore. Other reasons that we might
care is pressure sores can be very costly. It’s estimated that about
25% of the total cost for treating someone
with spinal cord injury over a lifetime is
related to pressure sores. So unfortunately spinal cord
injury is an expensive situation to be in, and to the extent
that one can reduce that cost, it’s often very beneficial. And then I think probably the
biggest reason that we care about pressure sores
are the personal costs. The thing that is often
so upsetting to folks when they do develop
pressure sores is that it changes their life. They’ve adjusted to perhaps
having a spinal cord injury and now they’re on bed rest
and they’re not able to go about their kind of
baseline regular life. So pressure sores also often
contribute to a loss of income, as I mentioned, more expense,
and that can also be in the form of family or caregiver expense. There’s different negative
effects of prolonged bed rest, so just even if it seems
like you’re not as active as you perhaps were after
your spinal cord injury, the fact that you’re
just sitting in your chair is actually
providing some conditioning, and the extent that you’re
doing more than just sitting in the chair provides
even more conditioning. So if you’re laid up in bed for
months, that can be negative and have trouble adjusting your
blood pressure once you do start to get back up after
you’ve healed. Of course, there’s a lot of
personal suffering with being on a bed rest situation or
dealing with a chronic sore, and it certainly can
contribute to depression. And then finally,
pressure sores do end up causing death
in some instances. It’s estimated that about
7 to 8% of deaths in those with spinal cord
injury are actually in some fashion related
to a pressure sore. So I’m going to talk a little
bit about risk factors, those that are related to
the spinal cord injury, and then those are just part
of kind of life and things that can be prevented. So it’s obvious I think to most
of us that pressure sores happen when one is paralyzed, and also
when one has less sensation or a sensory impairment. That’s kind of a given. But some other things that
happen with spinal cord injury that maybe aren’t as obvious are
changes in collagen metabolism that happen after
spinal cord injury. So that’s basically
how your wound heals, and that is affected quite a
bit related to both changes in the skin and changes
in your circulation. So it can actually take
about five times longer to heal a wound after — or
below your level of injury than it does above
your level of injury. Certainly, folks who’ve had
spinal cord injuries are aware that you do have
some muscle atrophy. So if you think you spend
a lot of time on your butt and you’ve lost some musculature
in your buttocks area, those bony prominences are
now much more superficial and much more likely to
be causing some pressure that can contribute
to a pressure sore. And then altered circulation. Spinal cord injury affects
the nerve innervation to your blood vessels, and in that way it can affect
both your wound healing and the blood supply to tissues, putting up more risk
for a problem. So other factors, and these are
just factors that can be present in anyone but certainly
they could also be present in somebody with a
spinal cord injury. Hypogonadism or low
testosterone, that is known to be more common in men
with spinal cord injury, and it can also have
effects on wound healing, so that’s something
to watch out for. And if your providers don’t
check it automatically periodically you may want to
kind of cue them to check it at least every couple of
years, your testosterone level. Diabetes is a problem
for wound healing in every patient population, so
certainly it doesn’t help those with spinal cord injury. Fevers or illnesses
can be a challenge. Malnutrition, particularly
your protein levels, Vitamin C and zinc levels are very
important in healing wounds and maintaining healthy skin. And then certainly
smoking, as we all know, is risky in any situation,
but it can contribute more to peripheral vascular disease
and make it more difficult to heal a wound or more
likely to develop a wound. And then unfortunately
aging, which we can’t escape, often can contribute to a wound. We know your skin gets thinner
as you age, and it tends to be less tolerant to trauma
and sheering forces or kind of dragging or rubbing forces. And then also as people age
they tend to lose some strength, so your transfers that
were going really great when you were 25 might not be
going as well when you’re 75, and you might be more likely
to be dragging your butt across a surface and
getting an injury, an injury to your skin as well. So I’ll speak a little bit about
causes and then prevention, and then I think I’ll
turn things over to Beth. So obviously it’s
a pressure sore. The cause is pressure. I’ll get to it in my next slide. There’s a few other
causes as well. But it’s important to remember that it’s not just
really the hard pressure that could contribute to a sore. Long periods of low
pressure can be a problem, recurrent pressure, or short
periods of high pressure. So if you fall on your —
if you’re doing a transfer and then end up whacking
yourself, that can be some fairly
hard pressure that’s — or fairly high pressure
that’s relatively short. But if you forget to do a
pressure reliefs all day, that’s relatively less
pressure but constant and can contribute
to problems as well. It’s also important to
remember that tissues can vary in their tolerance or their
sensitivity to pressure. So our skin is actually
the most resistant. It can tolerate more pressure
than other body tissues, but muscle, because it’s
so metabolically active, if it’s subjected to a lot
of pressure for awhile, it’s not getting the oxygen and
nutrients via the blood supply that it should, so it can start to have problems quicker
than other tissues. So that’s often the
situation where you get — as I think Beth will talk
about, but you get more of a deep wound, where the
muscle underlying the skin has been injured, but the
actual skin is still intact. And it’s estimated that about
1 to 6 hours of constant sort of minimal pressure can
cause some tissue damage. So other things that can cause
pressure ulcers: sheer force. So it’s not just pressure, but
also dragging skin or tissues across a surface, so that’s why
we always are looking for people to get lift off their backsides
when they’re doing transfers and not just kind of
dragging their body parts across a surface. Positioning is certainly
an issue, and that can really be an issue
sometimes for lower limb wounds or for hip wounds that your
wheelchair may be causing pressure in different spots,
that you need to be kind of aware of or having
somebody — either you or someone
else check your skin so that you’re not getting
pressure over spots due to the way you’re
positioning your chair. And then we also know
that skin moisture and maceration is affected
by different irritants. So the ones we always worry the
most about are urine and feces, so obviously incontinence is
not desirable, for many reasons, but one of which is that it
can kind of aggravate the skin and reduce skin tolerance
to stress and then contribute potentially
to more skin breakdown. So I think I’ll talk just
briefly about prevention and then turn things
over to Beth. So I think one of the things
that’s sort of hammered into folks when they’re
on inpatient rehab and probably continue
to be hammered into them throughout the
rest of their life living with a spinal cord injury
is pressure reliefs. We recommend that you do
pressure reliefs every 15 to 30 minutes, that you
turn frequently in bed. I think the normal
recommendations are usually every 2 hours. Sometimes that can be stretched out to a little bit
longer durations. And then making sure that you’re
using appropriate wheelchair cushions and mattresses, and
that they’re also inflated. I think any therapist will
probably stay on you about that, but from time to
time we do see folks that just didn’t notice their
cushion wasn’t inflated and end up unfortunately with a
sore on their backside. Shear. It’s always
important to make sure that you’re not sitting
on wrinkled bed linens or like that, although I
think it’s probably tricky to make sure your bed
linens are perfectly smooth. But you also want to make sure
you’re not dragging your lower limbs across the surface
when you’re transferring, or that you’re not
dragging your backside across the surface
when you transfer. I kind of mentioned
positioning and moisture. Mental status is important. I think we prescribe
a lot of medications for different aspects of, or
different conditions related to spinal cord injury
that can be very sedating. Certainly alcohol or any other
kind of drugs that are used for abuse or recreation can also
cause some changes in your sort of your awakeness, alertness
level, and you want to watch out for those because
you may forget to do your pressure releases
or do sloppy transfers if you’re transferring
while drunk and get injured. Smoking. There’s lots
of reasons not to smoke. Skin health is definitely
one of them. As I mentioned, alcohol
use is not a good situation for keeping your skin healthy. I did mention low testosterone
as well, and if you haven’t had that checked you may want to
have it checked every few years. And then anemia as it relates
to your nutritional status as well is important, just to
watch out for good blood counts, a good diet, making sure you’re
eating a diet that’s high in protein, and also watching
your different vitamin levels. So I think we’ll do
questions at the end, so I’ll just turn
things over to Beth now.  >>Beth Hall: This part of the
presentation is going to be on prevention and management,
what to look for, what to do, what are the signs
of early skin damage. How do you know you
have a problem? You got to know your skin. That means you need
to look and feel. You need to establish a routine
where you’re checking your skin in the mornings before you get
up, before you get dressed, and you check your skin at
night after you go to bed. That includes looking
and feeling. If you’ve had a pressure
ulcer and it’s healed, you need to increase your
time, your sitting time slowly, like 15 minutes at a time, and always check
your skin after that.   Use a mirror if you’re able to. Designate a caregiver if you’re
not able to use the mirror. But I still feel it’s important that you know what
your skin looks like, because no matter how
devoted your caregiver is, that might change, but
your skin’s always going to be with you. Make use of the electronics
— iPad, iPhone, cameras. Take pictures. If you suspect breakdowns,
always use some kind of measuring device to
give you some measurement and perspective. These are just some areas
of the body to monitor. I know I usually think of the
sitting bones or the sacrum, maybe the heels, but this makes
me realize how many areas we have that you have
to be aware of. So what does it look like
when a pressure is starting. So pale compression. Area of skin is going to turn
reddish or pinkish, maybe shiny, there may be texture change,
maybe cracked, dry, hard, soft, warm, or some swelling
at the site. May look like a bruise. Dark complexion, the
area’s going to be darker than the surrounding skin. It may be shiny,
bluish or purplish, same kind of texture changes. Or the first thing you
notice may be a blister, which you might not
be able to see, but if you’re feeling your skin,
you can probably feel that.   Here’s some — hopefully
you can see that — just what it looks
like, early skin damage.   What do you do if
you suspect damage? The first thing you do
is remove the pressure. Perform a blanching test, and this is really
for pale complexion. Press on the discolored
area, it should turn white. Move your finger, it should — the color should
return in a few seconds. if it doesn’t, then you know the
blood flow’s been interrupted and skin damage has begun. If you have a discolored area, recheck it after 10
or to 30 minutes. If after 30 minutes the
area’s still discolored, you should assume that a
pressure ulcer hast started. Look for the source. Check your mattress. Is it providing enough
pressure redistribution? Check your wheelchair cushion. Is it inflated? Is it the right time to cushion? Is there a leak? Check your clothes for wrinkles
or big seams or pockets. Were there objects left in the
bed that you might have laid on or sat on in the wheelchair. Evaluate your posture
in the wheelchair. Your positioning bed,
are you making sure that all your bony
prominences are padded? Because if you don’t correct
the problem at the source, you might clear up
one pressure ulcer, but it’s just going
to happen again. Remember, every area of
pressure on the skin, no matter how small, needs to be
regarded as a serious problem, because of the potential damage
to the tissue you can’t see. Don’t be fooled into thinking
you only have a little problem. If you have the signs of skin
damage, take it seriously. Now, this is the four
stages of pressure ulcers, and two that can’t be staged. This is according to the National Pressure
Ulcer Advisory Panel. Stage I. Pale complexion,
site may be red or pink. Dark complexion, it’s darker
than the surrounding skin. The difference between
the Stage I and some early damage
is a Stage I ulcer, the discoloration will not
fade, and it will not blanche. And there’s some examples. The pictures get a little
more graphic after this. What do you do? You got to keep the
pressure off. If the area of damage is on the
ischium, on the sitting bones, you might want to stay
out of your wheelchair. If it’s on the sacrum, the
tailbone, the shoulder blades, you might want to stay
off your back in bed. You might want to check the
back of your wheelchair, make sure it’s not
causing pressure. Check your clothes. Again, look for the seams in
the pockets and the wrinkles.   On the heels and ankles and
feet, float them off a surface. You can hang them
off the end of a bed. Keep the area clean and
dry, and don’t rub it. And good nutrition
aids in healing and helps maintain healthy skin. So you got to watch what
you’re eating, include protein, Vitamins A and C, iron and zinc. Increase your water intake. Stay hydrated. Dehydration can cause
problems, too. Check the site at
least twice a day. Find and remove the pressure. Review your transfer and
pressure relief techniques and check your equipment. If the reddened area seems
to be caused by friction and you just can’t stop it, you
might try transparent dressing. That kind of helps you
slide over a surface. And these are some things
to use or some things to evaluate when
pressure occurs. There’s splints that
can help your feet.   If you follow the
appropriate treatment, a Stage I pressure ulcer can be
resolved in about three days, but if you can’t heal it from
the methods we talked about, contact your healthcare
provider. Early detection and appropriate
treatment can prevent future problems. Stage II. This is a
break in the skin. It’s considered a
partial-thickness injury. Stage I was just on the
surface, the epidermis. Stage II goes through the
epidermis, and it’s now into the dermis, which is the
tissue underneath the skin. It presents like a
shallow, open wound. The tissue looks red, may
or may not have drainage, may or may not be —
it may be dry or moist. This is what it could look like.   It’s a treatment. Keep the pressure off. Look at your diet. Increase your protein. Keep the ulcer clean and
the surrounding skin dry.   You really need to contact your
healthcare provider for this, and they can recommend some
wound care or dressing choices. Look for signs of healing, look
for signs of it getting worse or signs of infection. Monitor it closely. Take pictures and
measure it weekly. Usual healing time, three
days to three weeks. Here are some signs of healing. The ulcer gets smaller,
shallower, some pinkish tissue starts
to form around the edges. It’s time to close up. Wound surface may
be smooth or bumpy. It’s beefy red, and you may have
some bleeding, but that’s good. Shows you’ve got some
good circulation. And signs it’s getting worse. You get an increase in size, increase in depth,
increase in drainage. You might get a lot of
soft dead tissue form or some black necrotic tissue. Might start smelling. Drainage might be greenish. You might develop a fever.   That’s when you really
want to call your doctor. A Stage III pressure ulcer. This goes through the epidermis,
through the dermis, and it’s now under the subcutaneous tissue,
which is the fatty tissue. Presents as a deeper crater. Appears red, may have
necrotic tissue on it. This is considered a
full thickness injury. The necrotic tissue can be
white, yellow, gray, black, and the dead tissue needs to be removed before
healing can occur. It’s got to make room
for some healthy tissue. And there’s some examples of
the Stage III pressure ulcer. Treatment.   Probably noticed by now,
get the pressure off. Notify your healthcare provider.   Maintain good hygiene
and dry skin. Look at your diet,
increase your protein, watch your fluid intake. This kind of wound often
requires packing or some kind of debriding agent, and
maybe even an antibiotic, if it shows some
signs of infection. Measure it weekly, take
pictures, share the pictures with your physician, your
home healthcare nurse. And then by this
stage you’re looking at some prolonged bed rest. You may qualify for
a special mattress. Pressure redistribution
mattress, what kinds you get is
determined by the number of turning surfaces you have. And that’s determined
by the number of pressure ulcers you have. Check your equipment to look
for the cause of these things. Check your pressure
relief techniques, too, and your transfer techniques. Usual healing time, if you follow the appropriate
treatment is 1 to 4 months. That’s a long time. Here’s some signs
it’s getting worse. You got a lot more dead tissue,
and this is starting to extend into the surrounding tissue,
and undermine, maybe tunneling. Signs it’s getting better. Decrease in necrotic tissue. The cavity starts to fill in, and you get that pinkish
tissue around the edges. Stage IV pressure ulcer. This is a full thickness wound. It goes through the
epidermis, through the dermis, through the sub-Q tissue and is
now into the muscle and can lead to the bone, the tendon
or the joint capsule. It’s a large cavity wound with
undermining and tunneling, often with necrotic tissue,
usually lots of drainage and infections common.   There’s some examples. You got to keep the
pressure off this. You got to look at your diet,
increase your protein intake.   You may need supplements,
vitamins.   You need to keep the ulcer
clean and surrounding skin dry. You need to keep accurate
measurements and take pictures. By this stage you’re
looking at more contact with your healthcare
provider or wound clinic or home health nurse, which
just adds more disruption to your life. By this time you’re going
to need a special mattress, prolonged bed rest, and possibly
even temporary placement in a skilled nursing facility. Signs of healing. I kind of think that this one over here is this one
before it was debrided, so that got nice and cleaned up. This one looks like it got — it’s filling in and you
can see that pink tissue. It’s trying to heal. The signs it’s getting worse. It’s starting to
spread and extending into surrounding tissue. There’s signs of infection
and probably evidence of bone or tendon damage.   Now, we move onto the
unstageable pressure ulcer. It’s covered with
necrotic tissue. It can’t be staged, because
if you can’t see the base of a wound, you can’t stage it and you can’t determine
the extent of the damage. Necrotic tissue may be
tan, gray, green, brown. It may have this thick
scab or eschar on it. That can be tan,
brown, or black. There’s some examples.   So the treatment. Keep the pressure off. Notify your healthcare provider. The necrotic tissue must be
debrided before the ulcer can be staged and healing can begin. And you want to cover it with a
dry dressing until you’re seen by your healthcare provider. if there’s a big cavity,
you want to gently fill it with some absorptive gauze.   Then there’s suspected
deep tissue injury. Skin’s intact but looks bruised. The tissue damage is at
the bony tissue interface, where the tissue meets the bone. It’s not yet reached
the surface of the skin, but these often develop into a
Stage III or IV pressure ulcer. And it can be caused by
friction or charring. On the feet it’s pretty common. So what do you do? Get the pressure off. Check your equipment. Check your shoes. Are they slipping on your feet? Are they too tight? If you do have a blister,
you want to cover it with a clean dressing
until you’re seen by your healthcare provider. And like I said, these
develop into a Stage III or — can develop into
a Stage III or IV. You cannot determine a healing
time for these until the extent of the damage is known. Principles of wound care. Number one, eliminate pressure. This can be a serious disruption of your life, like
Dr. Crane said. The treatments required to successfully heal pressure
ulcers can have a negative impact on your ability to work,
maintain your job, attend school if that’s what you’re doing, or even just participate
in your social life. You need local wound care. The necrotic tissue
has to be debrided. There’s four types
of debridement. The standard of care
is moist wound healing. So the wound needs
to stay moist. Topical treatment can be used,
like an enzyme, to kind of break down dead tissue, an
antibiotic ointment if there’s some signs
of local infection. If it’s draining a lot, maybe your healthcare provider
will recommend a filler. That can be a paste, powder,
or beads, or an alginate that absorbs a lot of drainage
— which cuts down on the number of times you have
to do wound care, which helps in some respect. And there’s lots of other
things on the market — medihoney, silver,
growth hormones, all the topical treatments
ordered by your healthcare provider.   Monitor and measure. Look and feel. Take pictures. Use a measuring device when
you’re taking the picture. Keep in contact with
your healthcare provider and share those pictures.   And the application
of an outer dressing. There’s lots of types,
lots of manufacturers, but only a few major categories. Foams, gauze, hydrocolloids. They’re very occlusive,
they really absorb moisture. Hydrogels, primarily
made of water or glycerin and they’re moisture retentive,
in case your wound is dry. Transparent films — moisture
retentive, non-absorb — they don’t absorb anything, but
they are helpful if you want to save your skin
when you’re sliding. These are some examples. The dressing choice depends on
the amount of drainage, the size and stage of the wound, and
the frequency of wound care. Poor nutrition prevents the
body tissue from rebuilding, staying healthy,
or fight infection. You need to eat a balanced diet
with adequate protein, fruits, vegetables, grains and fats. if you question your
nutritional status, talk to your healthcare
provider. He can get some lab work
done to see where you stand and what you need to do. Sometimes supplements like Ensure might be the easiest
way to get extra protein. Multivitamins can help. Your protein needs double when
you have a pressure ulcer, because so much is lost
through the wound, and it takes so much to rebuild tissue. Protein intake for your
average adult, 150 pounds, is .6 to .8 grams per
kilogram body weight per day. And you can see if you have
a Stage II pressure ulcer, it doubles. An example of the .6 to
.8 is 1.5 chicken breasts and a 7-ouince steak each day. It almost triples if you
have a Stage III or IV, so you’re looking at
a lot of food to eat. That’s where the
supplements kind of come in. If you’re monitoring your skin
closely, you should be able to detect a change in the early
stages and treat it accordingly. What you do to prevent
ulcers today, because aging increases
the chance, you need to have
ongoing assessment so you can modify
your routine to adapt to your skin’s changing needs. It changes, and that’s hard
for people to understand. At the first sign of skin
damage, get the pressure off. Look at your pressure
relief techniques. Check your equipment. If you develop a pressure ulcer
and you treat it appropriately, you can probably heal it. But if you don’t find the
cause of it and rectify that, it’s just going to happen again. Once you have a pressure ulcer,
once it’s healed, the strength of that tissue is only 80% of
what it was prior to injury. So you can see over time, if you just keep reinjuring the
same area, it’s not very strong. And don’t be afraid to ask
your healthcare provider for some help. They’re there to help, and I
don’t think anybody expects you to do this by yourself. I’m going to turn it
back over to Debbie.>>Deborah Crane: I just
have a couple minutes to talk a little bit about
surgical interventions or pressure sores, and I don’t
have any more scary pictures. So we all hope that you never
need surgical intervention for a pressure sore,
but the reality is, it’s not that uncommon
that people do. It really is an option
of last resort, so we really encourage folks
not to think of it as something as you know, I don’t need
to get the pressure off, as Beth reminded us so much, but I can just have a
quick surgery if I need to. It’s not an easy
fix, and as I’ll get to in a little more detail, it really does require very
prolonged bed rest and healing. And unfortunately the
surgeries fairly commonly have complications or failures. So we really do try
to think of this as a very last resort
kind of situation. So sores, pressure sores that
may be amenable to surgery, or where — situations
where your physician or provider may start to think
about getting a plastic surgeon to evaluate things and see
if you may be kind of headed down that way, are
Stage III and IV ulcers, so those real severe ones,
particularly when bones or joints are involved. So if you can see some bone
at the base of your wound, you probably are going to be at
least meeting with a surgeon. Also, sores that have what
are called sinus tracts, so those are kind of like
little cavernous areas where maybe your provider or
nurse can get a little Q-tip in there, but it’s
not really a base, a wound with a nice open
base, so it’s often hard to get those little
tiny tracts healed up. Sores that have significant
undermining, so that’s a situation where
you may have a wound base and then you have tissue that
surrounds it but there’s kind of a border that goes around that there’s an emptier
kind of cavernous space. That can be kind of
tricky to heal up. And then chronic ulcers that perhaps you’ve been
doing great wound care, you’re doing everything
right but it’s just sort of what we call stalled,
and it’s not progressing. So sometimes then
those will need to be evaluated for surgery. So looking a little
bit at the risk for complications and failures. There was a study done
that was led by a group of plastic surgeons at the
Seattle VA where they looked at — they reviewed
the charts of folks that had had pressure ulcer
surgeries, and they found that only about a
quarter of those healed without any complications. so almost 75% of folks who
had surgeries had some sort of complications. Sometimes they weren’t
all that major. It was a stitch popped early
or a small little infection or something, but sometimes it
was the whole flap fell apart and the person had to go back
through the whole thing again. It’s estimated it’s a pretty
wide prevalence there, but it’s estimated
that recurrences where you’ve had surgery at that
same site happened somewhere between about 19
and 64% of the time. And new ulcers in
a new spot happen around 20 to 30% of the time. Looking at — folks
always try to figure out, who’s the right candidate
for surgery? Is there a group of people
that probably are going to respond well and
there’s a group of people that aren’t going to respond
well, and there’s been a lot of studies looking at, is
it young people respond well to flap surgeries or old
people do, or these people do. And they all kind of — one
study says young people do; the other study says
old people do. Uniformly the one thing
they can all agree on is that smoking is a bad
contributor to the surgery. So that’s kind of the only
thing they seem to agree on, that everything else is
kind of all over the map. So there are surgeons — in
our protocol at Harborview, we strongly encourage kind of
mandate folks to quit smoking. Some surgeons really won’t
consider doing surgery if somebody’s still smoking. And then kind of what to
expect if you’re headed down the surgical route. So you would go through
evaluation. You’d be working with a wound
care nurse probably before all of this, and then if you
actually are going to end up having surgery, you’ll
usually come out of surgery on IV antibiotics, for
often several days to weeks. They’ll usually leave surgical
drains, and that’s just to drain any excess fluid so it
doesn’t build up in your skin in place for days to weeks. It kind of depends on how
much drainage you might have. You’ll end up being on a
bed rest for at least 2 if not more, like 4 weeks. And that will initially
be an air fluidized bed, so that’s kind of a
quicksand kind of bed. It’s filled with sand, and
then air is blown through it, so it’s very minimal pressure. After you graduate out of
that, your skin’s looking good, you get on to relatively
a normal hospital bed or a low-air loss bed that
we have in most rehab units. And then you’ll start doing some
range of motion with therapists, and then finally after all
this starts sitting and kind of getting back to more your
regular life, but you’re looking at through all of this, probably at least 4 weeks
if not more like 6. So it’s a lengthy proposition,
and often this is all going on either in the hospital
or in some situations in a nursing facility. So I think that’s
everything that we have from the medical end, and I
guess we’ll be turning things over to Chuck and Keith.>>My name’s Keith Mullen. I’ve been in a wheelchair for
almost 40 years, 38-1/2 years, so it’s been a long time. So I’ve had my share of skin
breakdowns through those years. And it’s my fault,
and that’s kind of what I want to
try to get across. The professionals are right. It’s our job. It’s not their job. Their job is to answer your
questions and fix you up. It’s our job to monitor and it’s
our job to have somebody look. It’s my job to feel, to touch,
to grab the mirrors to look to see and every night, and to
know what each wound looks like, because every one’s going to
be different that you get, if you get them on your side, if
you get them on this and that. Some of them heal faster. Some of them don’t heal faster, some of them require
surgery like they said. None of them are fun,
so it’s your job. It’s nobody else’s job. You need to be proactive. As you know in this wheelchair
life, the more proactive you are with your skin, with your
healthcare providers, with the nurses, with everybody
involved with your life, the easier and better
off you are and the easier it makes
everything for you. So get involved, espeically
when it comes to your skin. Make sure that whoever
is washing your skin for you knows what you want
your skin to look like, and not what they want your skin
to look like, because their idea of what healing is or what
better is or what sore is even, to you it just may be
redness and might be okay. Or it might be redness
and it might not be okay. So you have to understand your
skin 100%, and advocate that. Like they were saying, I got
a new healthcare provider after I turned 50, I’m teaching
him what it is about skincare. So it’s a learning
process for all of us. Be proactive. Thank you.>>I thought this was very good. And you started to talk
about routines, and routines that really are good
for prevention. Could you just reiterate some
of the routines that you do like throughout the day, like
starting from when you wake up in the morning to the
time you go to bed at night, what you’re doing to prevent
pressure ulcers, that you kind of put together a lot of
experience that’s very valuable.  >>Well, okay, first I wake up
and I kiss my wife good morning. But I get up and I
exercise my legs. I get up every morning
and I exercise my legs. I kiss my right one and say
I love me every morning. And I stretch them
out, do my exercises. I do little push-ups
when I’m laying on my stomach to begin with. I do my breathing exercises. I do the old-fashioned,
gasping, breathing exercise to get things moving and
flowing in the morning. I stretch all my legs out. And then get dressed. And I am a stickler for good
transfers, good technique in transfers, because it
saves you a lot of wear and tear everywhere — on your
butt, cleaning your wheel. You got to use great mechanics. Being tall like I am, I have to
make sure that my tripod is set up in my arm and my feet,
so I do a good transfers over so I don’t scrape
my butt going across the wheels and stuff. And also good mechanics for my
shoulders, because being a quad, I have to use the right
mechanics to lift myself over. And many times I’ve had my
arm stretch out too far in, and you tweak a shoulder muscle, then you start tweaking
another shoulder muscle, and all of a sudden you
got a sore shoulder. So start out with that. But morning-wise, either my wife
does a visual on the backside. I feel my backside in my problems areas
every morning anyways, before I even lift my
head off the pillow. And Mary usually does a
visual in the morning, make sure there’s no red spots. That’s an every morning and
every evening type thing, because in the evening, after
sitting all day, you’re going to have little rings around
some — everybody gets that, and then just to make sure that
they’re gone in the morning. And then at night,
you lay down, relax, maybe do some more stretching,
and then do another visual and that’s pretty much it. I took my commode chair and
took it to a good upholsterer and had it upholstered
with two-inch foam add. So I sit on a padded
commode chair. And my vehicle, I sit on a two-inch memory
foam gel in my van. And my bed is a Sleep Comfort
bed, air bed, adjustable, air pressure with three
inches of memory foam on that so you can adjust it. If you have problems, you can
adjust it down for your — if you have sore shoulders,
you can make it softer.>>Great, thank you.>>Yeah.>>You keep saying go
to your healthcare — consult your healthcare
provider. Most healthcare providers
I know don’t know squat about pressure sores. So my question is sort of
when do you up the ante. Which healthcare provider
do you consult, and when?>>Deborah Crane: I
guess if it were me or if it were my family member
or whomever, I’d probably say if you live in Seattle or
in the kind of surroundings and have access to one
of the rehab nurses or the rehab providers,
I’d probably go there. Because I think you’re right,
that it’s just not an area that people get too
much exposure to. I think most primary provider, primary family doctor type
providers probably see one or two spinal cord injured
people in their practice, and they just don’t see enough. So I think if you’re in an area
where you have a fair amount of access to somebody
with spinal cord injury and rehab experience, that’s
probably where I would start. If you’re living in an area
of really far outlying area, I’d start with who’s available. But I think hopefully in
our clinics, both at the UW and Harborview, I think,
we at least try to have — if you can’t see the nurse
practitioner or the physician, the nurses do have
appointments that you can, and often they’re really more of
an expert than the physician is. So you can get into
see those nurses.>>We saw a lot of skin surface, and that’s all you really have
access to, is your skin surface. But Dr. Crane made a very
good point, where if you bump or bruise yourself, where
that muscle is in contact with the bone is frequently
where ulcers start. So if you do something
like that to yourself, you got to ask yourself,
did you bruise yourself? So I’ve often advised people,
if you do something like that, you have a bad transfer,
give yourself a break. You got to get off it
for a period of time. Don’t really push your
sitting after that, to know that you’re
kind of over it. Because frequently a pressure
ulcer will present itself — it’s like a boil that
comes to the surface. And that’s a situation
where there was a bruise between the muscle and
the bone that caused it, because really the muscle
is more pressure intolerant than the skin itself. And the other point that I want to make is you’re
always wondering, well, are you getting a
pressure ulcer? And so you’re looking, you’re
feeling, but I would also add in spasticity, because
spasticity can be your friend. Your limbs start shaking
a lot, or you have — it’s a lot tighter, frequently
that’s been a signal to me that I’ve had a pressure ulcer. So for instance, this knee
got a little breakdown from running into doors. And so this leg became more
spastic, and that clued me into healing this knee. I even, when I climb
on my stomach, I have a little knee
protector that I put on there over my dressing to
kind of reduce the sheer and pressure there, or that
just makes me spastic at night. But spasticity is also
another real good signal that you may have done
yourself some wrong.>>We want to really thank Dr.
Crane, Miss Hall, thank you, Keith, for talking
with us this evening. We appreciate the participation
of all the audience members, and thank you very much
for coming tonight. [ Applause ]

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